Guilford_Well Abandonment_20221205

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WELL ABANDONMENT RECORD For Internal Use ONLY: '
1.Well Contractor Information: WELL ABANDONMENT DETAIL'S
RA 5s0 V J Qr'%e 6 1AT e—(- 7a.For Geoprobe/DPT or Closed-Lbop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hislher property) well construction/deptb,only 1 GW-3,0 is needed. Indicate TOTAL NUMBER of
wells abandoned:
,0 g(4
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s)s _(gaL)
R ,J (Lk r-ne:f W e r i an� pum P V,X-4 _ FOR WATER SUPPLY WELLS ONLY:Company Name 7c.Type of disinfectant used:'ht a 0 o c 610 r;ke-CC h 1 D r.n e)
2.Well Construction Permit#:dal 1 ©n 2
List all applicable will construction permits(i.e.UIC,County.State,Variance,etc.)iJlviown / �jne+��' rice t, \ct r -
7d.Amount of disinfectant used:/� © �- -
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑M cipaUPublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) iPitesidential Water Supply(single) ❑S d Cement Grout O Dry Clay
❑IndustriaVCommercial ❑Residential Water Supply(shared) Concrete Grout ❑Drill Cuttings
❑hri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other_(explain under 7g)
OMonitoring OReeovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge '❑Groundwater Remediation U CLC A5 Co r-%C`c.}
e q f'O LA-It --
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer t❑Geothermal(Beating(Cooling Return) ❑ in e Other(expla 7� - , C'P m en �1C t.t e-k k c\n A POJr1 0__�
/ ` nece� 'CC ID LLA 'cat.:x fco b o l o ram.-�o
4.Date well �I A s)abandoned:� a 1lhSd�cl'(�tt`�13w. 7t�rt
r • XDC V6, 2O276 �Cw," � GOr C rC5 ✓C, t 6 , V,
5a,Well location: I}rv'(iM 1 M VYi -
J 8:CerHfi a
Facility/Owner Name Facility IDk"ap
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t`3b�4S mCCOI,v\ A ,)se_ t,C:,-66ro 9.0- /G 2,k/ 2o2z
Ph sisal Addras,City,and Zip Signature of Certified Confractor or Well Owner Date
��©4 �r�c' �S By signing this form,I hereby cei7ijy that the well(s) was(were)abandoned in
County Parccl Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200-Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tattlong is sufficient) 9.Site diagram or additional well details:
!? �)`� `1 N ',C� '�(y 3 3 w You may use the back of this page to provide additional well site details or well
s? d abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELti(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifacallable..For multiple injection or non-water supply walls
ONLY with the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: �® (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the-form to the address in l0a
6e.Borehole diameter: (1n.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
G Division of Water Resources;Underground.Injection Control Program,
6d.Water level below ground surface: (fL) 1636 Mail Service;Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):LUX ltl n 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known):i .�i�' ft.) abandoned
6g.Screen length(if known):h d JC c-a e- ►� (ft,)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Rasotulccs Revisod 2-22-2016

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